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Salivary Gland Tumors

Sasan Dabiri, M.D. - Assistant Professor

Department of Otorhinolaryngology – Head & Neck surgery

Amir A’lam hospital

Tehran University of Medical Sciences

Epidemiology

• Overall prevalence:

– 3% of Head & Neck neoplasms

– 100 parotid neoplasms

– 10 submandibular neoplasms

– 10 minor salivary gland neoplasms

– 1 sublingual neoplasm

Salivary Gland Tumors

Epidemiology

• The most common neoplasms:

– Benign in anywhere:Pleomorphic Adenoma

– Malignant in parotid:Mucoepidermoid Carcinoma

– Malignant in others:Adenoid Cystic Carcinoma

– Post radiation, benign: Warthin’s tumor

– Post radiation, malignant: Mucoepidermoid Carcinoma

Salivary Gland Tumors

Fine Needle Aspiration / Biopsy

• Goals are:

– Differentiation of neoplastic and non-neoplastic mass

– Differentiation of benign and malignant neoplasm

• High specificity (96-98%)

• Good sensitivity (79-96%)

Salivary Gland Tumors

Fine Needle Aspiration / Biopsy

• Is it Accurate?

– Highest inaccuracy rates in Parotid

• Diversity in pathology ( 11 benign & 24 malignant )

• Other than mixed tumor, are uncommon

• Morphologically complex

• Some carcinomas have not malignant cellular appearance

Lower accuracy for diagnosing malignant tumor

Salivary Gland Tumors

Frozen Section

• Indications :

– Determination of tumor extension

– Evaluation of surgical margin

– Non-diagnostic FNA

– Incompatible FNA according to clinical judgement

Salivary Gland Tumors

Imaging

Salivary Gland Tumors

Imaging

Salivary Gland Tumors

Imaging

Salivary Gland Tumors

Imaging

Salivary Gland Tumors

Imaging

Salivary Gland Tumors

Imaging

Salivary Gland Tumors

Imaging

• Differentiation of benign and malignant tumors is not the primary goal of CT and MRI; but:

– Anatomical localization

– Local, Regional (lymph node), and Distant invasion

• Overall

– Low intensity in T1 & T2 malignant (high probable)

Salivary Gland Tumors

Imaging

• Why MRI is better than CT?

– Well visualized on T1 (especially parotid “fatty gland”)

• Excellent assessment of margins

• Deep extension & Infiltration

– Best mapping on T1+ Gd + Fat suppression• Bone marrow & cortex: hyposignal

invasion, well visualized

• Fatty & bony foramina at skull base: hyposignal

perineural spread: well visualized

• Meningeal invasion

Salivary Gland Tumors

Imaging

• Perineural invasion for parotid tumor

– Facial nerve

• entire nerve should be assessed all the way

( even if there is no clinical facial paralysis )

– Auriculotemporal nerve

• through a small fat pad along the

medial aspect of the lateral pterygoid muscle and just inferior to the foramen ovale

Salivary Gland Tumors

Imaging

• Perineural invasion for submandibular tumor

– Hypoglossal nerve

• Tongue movement impairment

– Lingual nerve

• Tongue tingling

Salivary Gland Tumors

MRI visualizes :• enlarged nerve• obliterated fat• enlarged ganglion• atrophy of the masticator muscles

Imaging

• Radionuclide Scanning (Tc 99m)

–Warthin’s tumor

– Oncocytoma

Salivary Gland Tumors

Helpful for elderly patients with parotid mass

Aldred Scott Warthin1866 - 1931

Imaging

• Ultrasonography

Pros

– Differentiation of glandular from extraglandular mass

– Guiding the biopsy (FNA)

Cons

– Operator dependent

– Just in superficial masses

Salivary Gland Tumors

Pleomorphic Adenoma

Salivary Gland Tumors

• Epithelial and

Mesenchymal

components

• 10% risk of

malignancy after

15 years

Warthin’s tumor

Salivary Gland Tumors

• Papillary Cystadenoma Lymphomatosum

• Only in parotid

• Male & cigarette smoking

• No risk of malignancy

• bilateral

Mucoepidermoid Carcinoma

Salivary Gland Tumors

• Contains mucoid

and epidermoid cells

• Low, intermediate

and high grade

classification

Adenoid Cystic Carcinoma

Salivary Gland Tumors

• Perineural invasion

• Grading according

dominant cells:

• Cribriform

• Tubular

• Solid

Management

• Surgery

– primary management in all new and recurrent cases

Unless :

• Surgery cannot be done (patient’s condition)

• Invasion to skull base

• Invasion to pterygoid plates

• Encase carotid artery

Salivary Gland Tumors

T4b

Management

• Radiation therapy ± Chemotherapy

– Unable to surgery

– Adenoid cystic carcinoma

– Intermediate or high grade carcinoma

– Close or positive margin

– Perineural or perivascular invasion

– Lymph node metastasis

Salivary Gland Tumors

In cases with complete resection

Thanks for Your Attention